HomeMy WebLinkAboutBLDTR-23-001145 f7)a-1 it/ 03/1ZZ
TONNA OF V.k.RNI(METII
BUIL DING lifrkRTNIENT Permit Number eLi) yr _35—
' South '
1146 Route 2$. S Yarmouth. NIA 112664
Date Issued d 0 //iii
...,r,;-:, , 1 503-398-22.51 evt. 261 FaN: :;08-398-0836
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Expiration Date ete/7 6`7
RECEIVED
TRENCH PERMIT
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) AUG 2 4 2022
THIS PERMIT MUST RE FULLY COMPLETED PRIOR TO CONSIDERATION BUILDING DEPARTMENT
By:
I Name of Applicant q Phone Cell
0-‘e•N.c\--) (--..\\.CAN
Street Addrm —11 L
City/Town MA ; ZIP —
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Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
-
Name of Owl-mils)of Property Phone Cell
Street '---Sc.,•cc\e5‘)-5-IUvet1r4s..1 r-N••\'0e"(A
Address 5uo -- 1-yi—OLL-i0
City/Town MA • ZIP
i
'c)• \kin((Y\0,.//cA' '‘N (;)(.-(0(d'‘
Other Contact I Permit Fee Received No( ) Yes( 1
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to
! be laid in proposed trench(eg:pipeskabk lines etc..)Please use reverse side if additional space is needed.
I
ec)-\-t cre,9\c‘ce0(\exA. @ C\
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1 Name and Contact Information of Insurer:
, N SL) s--n -\Go
,(‘cc---\.<\7. (1/4c.,\N (3 ),je, -LO
c... ,,_.k.,.. )0,..e.),_
\vc. . ___...
Policy Expirati;Wiis;te:75 j %- )..6 .
i Dig Safe#:
Name of Competent Person(as defined by 520(MR 7.02):
N'c•C•VC\ve..... We....\c...-\\ _________.....___
1 of 2
Massachusetts Hoisting Laccnse
License Grade. Esgirahon Date: .
BY SIGNING THIS FORM.THE APPLICANT,OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY
THAT THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMENT OF THE WORK,WILL BECOME FAMILIAR
WITH,ALI,LAWS AND REGU:ATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA MUTATIONS.
GI-. c. SZA. 520 CMR 7.09 et seq.. AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND
REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMI`t LSSUEI)FOR
SUCH WORK WILL ((IMPLY THEREWITH IN ALL RESPECTS AND WTIH THE CONDITIONS SET FORTH
BELOW.
THE UNDERSIGNED OWNER AUTHORI7ES "IEEE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER. AND ALSO. FOR 111E
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE
CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO
REIMBURSE THE MUNICIPALTT1t FOR ANY AND ALL COSTS AND'EXEENSES INCURRED BY THE
MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,
INCLUDING BUT NOT LIMITED TO E+1NFORCING,THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF
THIS PERMIT.INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH.AND MEASURES TAKEN BY THE
MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO
COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED
NECESSARY BY THE MUNICIPALITY..
THE UNDERSIGNED APPLICANT,OWNER AM)EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNWY.AND HOLD HARMISCS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING'OUT
OF ANY INJURY, DEATH, I.0SS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK
CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE O Lb_ _
Z.-
•is
�.xCAVAraR SIG If'DIFFERENT) 1 if/J a4'al'
�. DATA _-
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
2 of 2